MASS45 Adult Oxygen Initial and 4 Month Review

1 Medical Aids Subsidy Scheme, Queensland Health Applicant Information Sheet for mass 45. Adult Oxygen : Initial Application and 4 Month Review Applicants should retain this section for their records Eligibility Administrative eligibility is dependent upon the applicant being a permanent Queensland resident. The applicant must hold one of the following eligibility cards in the name of the applicant: Centrelink Pensioner Concession Card Centrelink Health Care Card Centrelink Confirmation of Concession Card Entitlement Form (conditions apply). Department of Veterans' Affairs (DVA) Pensioner Concession Card (conditions apply). Queensland Government Seniors Card Please provide a copy of both sides of the eligibility card, OR signed consent to access Centrelink information on the mass 84 Proxy Access to Centrelink Information Form.

2 Clinical eligibility will be determined by the Medical Aids Subsidy Scheme ( mass ) Clinical Advisor based on information provided by the mass designated prescriber as detailed in the mass General Guidelines. Domiciliary Oxygen is not provided by mass for hospital inpatients, residents of Commonwealth funded care facilities, Home Care Package Level 1 to 4 recipients and for applicants who are current smokers. How to Apply mass operates through a prescriber model in that mass designated prescribers, in consultation with the applicant, submit an application (on behalf of the applicant) to mass for consideration for funding assistance. The mass designated prescriber completes the application form in accordance with the General and Oxygen sections of the mass General Guidelines.

3 mass designated Oxygen prescribers are: Thoracic Physicians Specialist General Physicians Oncologists Cardiologists Palliative Care Physicians Respiratory Nurse Practitioners Neurologists Refer to Oxygen Designated Prescriber Chart in the mass General Guidelines for further details endorsement requirements for medical practitioners in rural and remote areas. Applicant Acknowledgement I confirm that: 1 I have been provided with information by my prescribing medical specialist regarding the safety aspects associated with the use of domiciliary Oxygen . 2 I am aware Oxygen can be a dangerous fire hazard if used in the vicinity of naked flames. 3 I am a non-smoker and I will not allow others to smoke near my Oxygen equipment. 4 I will use the Oxygen as explained to me by my prescribing medical specialist.

4 I acknowledge 5 the equipment subsidised by mass always remains the property of the that Oxygen supplier. 6 repairs must only be carried out by the Oxygen supplier. 7 I am responsible for loss of and / or damage of the Oxygen equipment. 8 the Oxygen and Oxygen equipment will only be used for the purpose for which it was prescribed. MASS45 05/2018 Page 1 of 2. Applicant Information Sheet for mass 45 Adult Oxygen : Initial and 4 Month Application Applicant Acknowledgement cont. 9. mass takes no responsibility for any injuries sustained through the use of the Oxygen and Oxygen equipment subsidised by mass . 10. mass will no longer be financially responsible for the Oxygen equipment when any of the following occur: I am advised by my prescribing medical practitioner that I am no longer clinically eligible to be provided with Oxygen through mass .

5 I am no longer eligible for a Pensioner Concession Card or Health Care Card. I no longer reside in the state of Queensland. I have moved into a Commonwealth funded aged care facility. I do not return the mass renewal application form by the due date. I agree to: 11 immediately contact the Oxygen supplier if there is any problem with the Oxygen equipment. 12 immediately contact mass or my local Community Health Centre to organise return of the Oxygen equipment when it is no longer required. I understand that this must then be followed by confirmation from my doctor in writing. 13 inform mass within 14 days of any change in my residential address or eligibility for mass subsidy if I am no longer eligible for a Health Care Card.

6 14 keep in good order the Oxygen equipment subsidised by mass . 15 promptly answer any enquiries made by mass in relation to my need for continued use of Oxygen and related Oxygen equipment. 16 (concentrator users only) check with my Oxygen supplier for instructions and advice if I decide to power my concentrator with a generator. I understand that generators require a minimum set of specifications for powering concentrators and this may vary between machines. mass Privacy Statement YOUR PRIVACY: The Queensland Health, Medical Aids Subsidy Scheme ( mass ) is collecting administrative, demographic and clinical data as part of the mass application processes, in accordance with the Information Privacy Act 2009 and Hospital and Health Boards Act 2011, in order to assess the applicant's eligibility for funding assistance for the supply of aids and equipment.

7 The information will only be accessed by Queensland Health officers. Some of this information may be given to the applicant's carer or guardian; other government departments who provide associated services; the prescribing health professional for further clinical management purposes; and to those parties ( community care, commercial suppliers and repairers) requiring the information for the purpose of providing aids, equipment and services. Your information will not be given to any other person or organisation except where required by law. Medical Aids Subsidy Scheme PO Box 281, Cannon Hill Qld 4170 Telephone: 07 3136 3510 or 1300 443 570 | Fax: 07 3136 3500. Email: Website: MASS45 - 05/2018 Page 2 of 2. The State of Queensland (Queensland Health) 2012 Contact Medical Aids Subsidy Scheme (Affix identification label here if available).

8 ( mass ) Queensland Health mass 45 Family name: Adult Oxygen : Initial Application Given name(s): and 4 Month Review This form is used for all Initial domiciliary Oxygen Date of birth: Sex: M F I. applications and the 4 Month Review application PART A To be completed by the applicant / carer Applicant's Personal Details 1 Name 8 Does the applicant receive a Department Yes Title Family name of Veterans' Affairs benefit? No Given name(s) 9 Does the applicant receive other Yes assistance? ( Dept of Communities /. Preferred name First name or specify Disabilities, Palliative Care services) No If yes, name 2 Date of birth Sex Male Intersex 10 Is the applicant of Aboriginal or Torres Strait Female or Other Islander origin? For applicants of both Aboriginal and 3 Permanent residential address Torres Strait Islander origin, tick both Yes' boxes.

9 Aboriginal Yes No Torres Strait Islander Yes No 11 Country of birth Suburb / town Postcode Australia Other 12 Language spoken at home Telephone Fax English Other Mobile Email Carer or Alternative Contact Person 13 Name 4 Delivery address Same as residential address Title Family name Given name(s). Suburb / town Postcode 14 Contact information Telephone Fax 5 Postal address Same as delivery address (for correspondence). Mobile Email Suburb / town Postcode 15 Relationship to applicant 6 Is the applicant receiving a Home Care Yes package? No NOTE: If the applicant is receiving a Home 16 Postal address Care Package, they will not be eligible for Oxygen mass funding. 7 Is the applicant a resident in a Yes SW p Z . Commonwealth funded care facility?

10 No SW8000. NOTE: If the applicant is a resident in a Commonwealth funded care facility, they will not be Suburb / town Postcode eligible for Oxygen mass funding. Page 1 of 6. Medical Aids Subsidy Scheme (Affix identification label here if available). ( mass ) Queensland Health mass 45 Family name: Adult Oxygen : Initial Application Given name(s): and 4 Month Review Date of birth: Sex: M F I. Alternate Contact Persons 17 Alternate Contact Persons I consent to mass , Queensland Health approaching my personal contacts should the need arise. The names and addresses of two (2) personal contacts who are aware that their names have been provided to mass , who do not reside with the applicant and who will always be aware of the applicant's address are: Personal contact 1 Personal contact 2.